Composite score for prediction of 30-day orthopedic surgery outcomes

The LACE+ (Length of stay, Acuity of admission, Charlson Comorbidity Index score, and Emergency department visits in the past 6 months) risk-prediction tool has never been tested in an orthopedic surgery population. LACE+ may help physicians more effectively identify and support high-risk orthopedics patients after hospital discharge. LACE+ scores were retrospectively calculated for all consecutive orthopedic surgery patients (n = 18 893) at a multi-center health system over 3 years (2016-2018). Coarsened exact matching was employed to create “matched” study groups with different LACE+ score quartiles (Q1, Q2, Q3, Q4). Outcomes were compared between quartiles. In all, 1444 patients were matched between Q1 and Q4 (n = 2888); 2079 patients between Q2 and Q4 (n = 4158); 3032 patients between Q3 and Q4 (n = 6064). Higher LACE+ scores significantly predicted 30D readmission risk for Q4 vs Q1 and Q4 vs Q3 (P < .001). Larger LACE+ scores also significantly predicted 30D risk of ED visits for Q4 vs Q1, Q4 vs Q2, and Q4 vs Q3 (P < .001). Increased LACE+ score also significantly predicted 30D risk of reoperation for Q4 vs Q1 (P = .018), Q4 vs Q2 (P < .001), and Q4 vs Q3 (P < .001).     

Refractory Heart Failure Dependent on Short‐Term Mechanical Circulatory Support: What Next? Heart Transplant or Long‐Term Ventricular Assist Device

Chronic heart failure is a progressive and eventually fatal illness. Although the disease cannot be cured and treatment is symptom oriented, most of the patients benefit from optimum medical treatment. Patients with rapid deterioration in chronic advanced heart failure refractory to medical treatment need inotropic support and may need intra‐aortic balloon pump to maintain circulatory support, which of course cannot be prolonged beyond a certain limit. The outcome of heart transplant and long‐term ventricular assist device (VAD) in such patients is poor. The short‐term mechanical circulatory support (MCS) offered to such patients not only provides effective circulatory support and stabilizes them hemodynamically, but also halts the ensuing or reverts the established end‐organ failure. As the name suggests, the short‐term MCS offers support for the short term, usually less than a month. Although some patients with acute heart failure experience recovery of myocardial function with short‐term MCS support, others become dependent. These patients, stabilized and “stuck” with short‐term MCS, can be “rescued” with long‐term VAD or heart transplantation. Both the procedures, when done in this special situation, have their inherent advantages, disadvantages, and complications and hence need the careful consideration about the choice of the procedure. We have tried to elucidate this situation by considering the advantages and disadvantages of both options.     

Dopaminergic Influences on Emotional Decision Making in Euthymic Bipolar Patients

We recently reported that the D2/D3 agonist pramipexole may have pro-cognitive effects in euthymic patients with bipolar disorder (BPD); however, the emergence of impulse-control disorders has been documented in Parkinson''s disease (PD) after pramipexole treatment. Performance on reward-based tasks is altered in healthy subjects after a single dose of pramipexole, but its potential to induce abnormalities in BPD patients is unknown. We assessed reward-dependent decision making in euthymic BPD patients pre- and post 8 weeks of treatment with pramipexole or placebo by using the Iowa Gambling Task (IGT). The IGT requires subjects to choose among four card decks (two risky and two conservative) and is designed to promote learning to make advantageous (conservative) choices over time. Thirty-four BPD patients completed both assessments (18 placebo and 16 pramipexole). Baseline performance did not differ by treatment group (F=0.63; p=0.64); however, at week 8, BPD patients on pramipexole demonstrated a significantly greater tendency to make increasingly high-risk, high-reward choices across the five blocks, whereas the placebo group''s pattern was similar to that reported in healthy individuals (treatment × time × block interaction, p<0.05). Analyses of choice strategy using the expectancy valence model revealed that after 8 weeks on pramipexole, BPD patients attended more readily to feedback related to gains than to losses, which could explain the impaired learning. There were no significant changes in mood symptoms over the 8 weeks, and no increased propensity toward manic-like behaviors were reported. Our results suggest that the enhancement of dopaminergic activity influences risk-associated decision-making performance in euthymic BPD. The clinical implications remain unknown.     

SCAI expert consensus update on best practices in the cardiac catheterization laboratory

The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.     

Mechanism of sulfidation of small zinc oxide nanoparticles

ZnO has industrial utility as a solid sorbent for the removal of polluting sulfur compounds from petroleum-based fuels. Small ZnO nanoparticles may be more effective in terms of sorption capacity and ease of sulfidation as compared to bulk ZnO. Motivated by this promise, here, we study the sulfidation of ZnO NPs and uncover the solid-state mechanism of the process by crystallographic and optical absorbance characterization. The wurtzite-structure ZnO NPs undergo complete sulfidation to yield ZnS NPs with a drastically different zincblende structure. However, in the early stages, the ZnO NP lattice undergoes only substitutional doping by sulfur, while retaining its wurtzite structure. Above a threshold sulfur-doping level of 30 mol%, separate zincblende ZnS grains nucleate, which grow at the expense of the ZnO NPs, finally yielding ZnS NPs. Thus, the full oxide to sulfide transformation cannot be viewed simply as a topotactic place-exchange of anions. The product ZnS NPs formed by nucleation-growth share neither the crystallographic structure nor the size of the initial ZnO NPs. The reaction mechanism may inform the future design of nanostructured ZnO sorbents.

In the sulfidation of small ZnO nanoparticles, the nanoparticles first undergo sulfur doping followed by the nucleation-growth of ZnS domains.

Zinc oxide (ZnO) nanoparticles (NPs), due to their cost-effectiveness and biodegradability, have a multitude of applications^1–3 including coatings^4–8 and pigments,^9,10 catalysis,^11,12 energy storage,^13,14 and environmental remediation.^15–22 ZnO NPs have particular appeal as sorbents for scavenging polluting sulfur compounds such as mercaptans and hydrogen sulfide (H₂S) from petroleum-based fuels:^23–27 ZnO + H₂S → ZnS + H₂O. Lattice O²⁻ in the ZnO is replaced with S²⁻ scavenged from the pollutant. Bulk powders of ZnO have already been used for adsorptive removal of H₂S,^28,29 but NPs have specific advantages. With smaller grain sizes, mass transport limitations are lifted.²³ Whereas sulfidation is limited to the surface of bulk ZnO, with NPs, the entire mass of ZnO can undergo sulfidation, enabling high sorbent capacity.²³ Volume and morphology changes resulting from restructuring of the solid can also be more easily accommodated with NPs,²³ allowing regenerable use of the sorbent. Finally, the high specific surface area of NPs allows more enhanced kinetics of the sulfidation reaction, potentially facilitating much lower desulfurization temperatures as compared to the conventional operating temperatures of 650–800 °C.^23,29In this context, small few-nm size ZnO NPs can be expected to be particularly promising, but it is important to understand the manner in which these NPs undergo sulfidation. The structural mechanism of the sulfidation process³⁰ may have critical differences compared to bulk ZnO powders or even larger NPs of tens of nm in size²⁴ and may therefore influence sorbent design. In a seminal study, Park et al.³⁰ studied the sulfidation of hexagonal-shaped 14 nm ZnO nanocrystals (NCs) at high temperature (235 °C) using hexamethyldisilathiane. The reaction was found to involve the anion exchange of O²⁻ with S²⁻ in the NC lattice. The overall shape and crystallography of ZnS NCs was templated by the initial ZnO NCs. However, due to the faster outward diffusion of Zn²⁺ as compared to the inward diffusion of S²⁻, the exchange reaction was accompanied by a nanoscale Kirkendall phenomenon, as a result of which the ZnS NCs formed were hollow.Here, we track the step-wise sulfidation of smaller (ca. 5 nm) ZnO NPs using optical spectroscopy and X-ray crystallography. Prior to the onset of sulfidation, O²⁻ in wurtzite ZnO NPs undergoes substitutional doping with S²⁻ without any major change in its structure. Upon reaching a critical concentration of sulfur doping, separate zincblende ZnS grains form and grow into ZnS NPs. Thus, the sulfidation of these small ZnO NPs studied here is not simply a topotactic or templated place-exchange of anions; rather the nucleation and growth of a separate ZnS crystallite is involved in the latter stages.